A case report describing a rare presentation of Acute Inflammatory Demyelinating Polyradiculopathy (AIDP)

Case Report | DOI: https://doi.org/10.31579/2690-1919/089

A case report describing a rare presentation of Acute Inflammatory Demyelinating Polyradiculopathy (AIDP)

  • Parvathy Ravi Sankar *

* Michigan State University College of Osteopathic Medicine 965 Wilson Road, East Lansing, USA.

*Corresponding Author: Parvathy Ravi Sankar, Michigan State University College of Osteopathic Medicine 965 Wilson Road, East Lansing, USA.

Citation: Parvathy Ravi Sankar, A case report describing a rare presentation of Acute Inflammatory Demyelinating Polyradiculopathy (AIDP). J Clinical Research and Reports, 4(4); DOI:10.31579/2690-1919/089

Copyright: © 2020 Parvathy Ravi Sankar. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 20 April 2020 | Accepted: 01 May 2020 | Published: 05 May 2020

Keywords: acute inflammatory demyelinating polyradiculopathy; molecular mimicry; polycranial neuritis; GBS; CSF; MFS

Abstract

Background: AIDP (Acute Inflammatory Demyelinating Polyradiculopathy) commonly presents as bilateral lower extremity weakness and areflexia with albuminocytologic dissociation on CSF findings. Sensory symptoms are not prominent presenting features in patients. However, Bulbar and Miller Fisher variants of AIDP are very rare. This case report highlights the unique presentation where unilateral facial nerve palsy along with perioral numbness and decreases taste sensation was the presenting symptom. 

Case presentation: A 33-year-old male with a past medical history of rhabdomyosarcoma s/p resection who presented with the chief complaint of numbness and dysphagia. He developed left-sided facial droop and decreased taste sensation following an episode of bronchitis six weeks ago. Pertinent positives include mild dysphagia, decreased appetite, congestion and rhinorrhea. Physical exam was not significant except for decreased sensation of the upper and lower left face, decreased sensation of the right lower face, decreased light touch of the right upper extremity, 3+ reflexes of both upper and lower extremities bilaterally.

Conclusions: This case report highlights the unique presentation of Bulbar AIDP with some symptoms of Miller Fisher syndrome. Predominant sensory symptoms such as perioral numbness and decreased taste sensation might be the predominant symptoms that bring the patient to attention. Hence, it is imperative to perform a lumbar puncture to support the diagnosis of variant AIDP when prominent sensory symptoms are present.

Background

Guillain-Barré syndrome (GBS) is characterized by a triad of rapidly progressing ascending paralysis, mild sensory loss and hypo- or areflexia. CSF analysis reveals albuminocytologic dissociation in 90% of casesa. Acute inflammatory demyelinating polyneuropathy (AIDP) is the most common form of GBS. In AIDP, the immune system targets the peripheral nerve myelin sheath with some axonal lossa. There are different presentations of GBS based on the types of nerve fibers involved (motor, sensory, sensory and motor, cranial or autonomic), mode of fiber injury (demyelinating versus axonal), and the presence of changing levels of consciousnessa. Miller Fisher Syndrome (MFS) is a variant of GBS which consists of ophthalmoplegia, ataxia, and areflexia without any weaknessa. Most patients have at least two of the above symptoms along with elevated CSF protein and positive autoantibodya.

Atypical presentation of GBS such as the pharyngeal-cervical-brachial variant can occur in the form of unilateral or bilateral facial palsy, dysphagia like symptoms due to bulbar muscles being affected mostly with or without other cranial nerve involvement, extremity weakness or ataxiab.

Case presentation

A 33-year-old male with a past medical history of rhabdomyosarcoma s/p resection who presented with the chief complaint of numbness. Patient admitted to a baseline level of numbness and tingling of the bilateral hands and feet as a side effect of the chemotherapy and radiation. However, he has noticed increased tingling of the right hand which is extending into the R forearm, perioral numbness and tingling with extension into the tongue, diminished sense of taste, left-sided facial droop and decreased ability to close the left eye. Patient admitted to having acute bronchitis six weeks ago for which the patient was given a course of Bactrim. Review of system were all negative except for the decreased appetite due to diminished taste sensation, blurry vision, mild dysphagia, right posterior neck pain, rhinorrhea, congestion and fatigue. Physical exam was negative except for decreased sensation of the right lower face, left facial droop with incomplete closure of the left eye, decreased light touch of the right upper extremity, 3+ reflexes of both upper and lower extremities bilaterally. Vitals were stable except tachycardia of 123 on presentation. Labs were not significant, and an MRI of the brain and cervical spine was done to rule out the possibility of leptomeningeal carcinomatosis and they were both negative for any acute pathology. A lumbar puncture was performed which showed an elevated protein of 117 mg/dl. The team discussed the likely diagnosis of Bulbar variant of Acute Inflammatory Demyelinating Polyradiculopathy (AIDP) and the patient agreed to a five-day course of IVIG. Upon the completion of the five-day treatment, patient stated that his symptoms are stable.

Discussion and Conclusions

GBS can be caused by infectious, inflammatory, or systemic diseases.  C. jejuni is the most common culprit with cytomegalovirus being the second most common infectious precipitants of GBS. However, EBV and influenza vaccination has also been implicated in a minority of GBS cases.

The main cell type affected in GBS are the motor or sensory neurons. Gangliosides are complex glycosphingolipids containing sialic acid and is present in the cell membranes of many cells and are concentrated in neuronal membranes and processesc. The immune system in GBS is mistakenly attacking myelin or axons which serve as the pathway for communication to and from the brain.  This autoimmune phenomenon occur because of the surface of C. jejuni contains polysaccharides that resembles the glycoconjugates of the nerve tissue membranesd. This is referred to “molecular mimicry,” wherein a single B- or T-cell receptor recognizes a microbe's structure and an antigen of the host at the same timed. As a result, these activated lymphocytes migrate across the endoneurial capillary walls and attract macrophages to cause an inflammatory response against the peripheral nervous systemd. It is these macrophages that invade the basal lamina of the Schwann cell and degrade the myelinated axons. Location where this phenomenon takes place will determine the corresponding neurological deficit seen in the patient. The electrophysiological features seen include multifocal slowing of nerve conduction and partial conduction blockc.

There are very atypical presentations of GBS such as polycranial neuritis and acute bulbar palsy plus syndrome where patients present with oropharyngeal weakness with or without other cranial nerve involvemente. In these rare forms of GBS with very nonspecific features, neuroimaging has become an important tool since the postgadolinium enhancement of the peripheral nerve roots and cauda equina is evident on spinal MRIe. The pattern of enhancement can provide diagnostic clues about the type of demyelinatione. The enhancement of the dorsal and ventral root is commonly seen in AIDP compared to anterior root enhancement seen in acute motor axonal neuropathy (AMAN)e. Cranial nerve enhancement has been noted in MFS and polyneuritis cranialis forms of GBSe. This enhancement occurs because of the breakdown of blood brain barrier due to inflammatione.

This case report highlighted the importance of keeping a wide differential when patients present with oropharyngeal and facial weakness in the presence or absence of hypo/areflexia and other cranial nerve palsies. It is imperative that to think of bulbar AIDP variant and obtain a lumbar puncture to further help with diagnosis and management of these patient.  

Abbreviations

Acute motor axonal neuropathy (AMAN)

Miller Fisher Syndrome (MFS)

Acute Inflammatory Demyelinating Polyradiculopathy (AIDP)

Declarations

Ethics approval and consent to participate

Not applicable

Consent to publish

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Availability of data and materials

Not applicable

Competing interests

The authors declare that they have no competing interests

Funding

No source of funding was needed to report this case

Authors’ contributions

PS collected the information, researched about the topic and wrote the report.

Acknowledgements

I would like to thank Dr. Ward and the entire Neurology team for their undue support and guidance during my time with the service. 

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad